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NICE referral advice: 2. Acute low back pain

NICE has published Referral Advice – A guide to appropriate referral from general to specialist services, which deals with 11 common complaints. Last month we covered acne; in this issue we reproduce the advice on acute low back pain.

The referral advice is set out in consensus statements based on the best available evidence. It is designed to help clinicians determine how urgently particular patients need to be referred. For a summary of the consensus statements click here.

Acute low back pain is common, often severe and usually benign. In the majority of patients the episode resolves spontaneously within 6 weeks.

Management depends on establishing a working diagnosis in which patients are divided into those with pain associated with serious spinal pathology (around 1% of consultations) or nerve root compression (up to 4%), and those with mechanical (simple) low back pain (around 95%).

The pain associated with serious spinal pathology varies depending on the underlying cause. In those with cancer or infection, pain usually starts gradually, is progressive, unremitting and ultimately unrelenting; it is often worse at night. Suspicion should be heightened when symptoms develop before the age of 20 years or after 55 years, and in those who have systemic illness or a past history of cancer.

In those with pain due to trauma or osteoporotic vertebral fracture, it is usually of sudden onset, affected by posture or movement, and gradually improves with time. In those with pain from inflammatory spinal disease (e.g. ankylosing spondylitis), pain is typically generalised and associated with early morning stiffness.

Nerve root compression, which is often accompanied by numbness, tingling or weakness, commonly radiates to the calf, foot or toes. Classically, symptoms are worse in the legs than in the back.

Simple acute low back pain is felt in the lumbosacral region, buttocks or thighs, varies with physical activity and, over time, is exacerbated and/or relieved by mechanical factors, and is not associated with systemic upset. Classically, pain is worse in the back than in the legs.

By convention, the symptoms of acute back pain last less than 6 weeks. However, pain may persist or relapse over the following year. In addition to relieving pain, the aim of treatment is to return patients to their normal activity as soon as possible, which may help reduce the likelihood of developing chronic pain or disability.

Initial management strategies for patients with simple acute low back pain include reassurance as to the benign nature of the pain, avoidance of bed rest, encouragement to maintain their normal activity, education on posture and lifting, manipulation therapy, physical therapy and exercise programmes to help restore function.

Drug treatment typically includes effective analgesia (see the Royal College of General Practitioners' Guidelines on the Management of Acute Low Back Pain). In a patient with simple low back pain X-rays are best avoided.

These are in a position to:

confirm, establish or exclude diagnoses

provide management advice coupled with physical therapies

provide specialist therapists and pain teams to help treat and advise

arrange or undertake surgical intervention and rehabilitation.

Referral Advice

The majority of patients with acute low back pain can be managed in primary care. They should, however, be referred to a specialist service if:

they have nerve root pain that is not resolving after 6 weeks (preferably seen within 3 weeks)

an underlying inflammatory disorder such as ankylosing spondylitis is suspected

they have simple back pain and have not resumed their normal activities in 3 months. The effects of pain will vary and could include reduced quality of life, functional capacity, independence or psychological wellbeing. Where possible, referral should be to a multidisciplinary back pain team

Key

The starring system developed by NICE to identify referral priorities

Arrangements should be made so that the patient:

is seen immediately1

is seen urgently2

is seen soon2

has a routine appointment2

is seen within an appropriate time depending on his or her clinical circumstances (discretionary)

1 within a day

2 health authorities, trusts and primary care organisations should work to local definitions of maximum waiting times in each of these categories. The multidisciplinary advisory groups considered a maximum waiting time of 2 weeks to be appropriate for the urgent category.

Reproduced with kind permission from: Referral Advice – A Guide to Appropriate Referral from General to Specialist Services. London: NICE, December 2001.

The complete document can be downloaded from the NICE website www.nice.org.uk